NUJHS Vol. I, No.

4, December 2011, ISSN 2249-7110

Nitte University Journal of Health Science

Original Article

CONCEPT MAPPING – AN EFFECTIVE TOOL TO PROMOTE

CRITICAL THINKING SKILLS AMONG NURSES
T. Nirmala1 & B. S. Shakuntala2
1
Vice Principal, PSG College of Nursing, Coimbatore, Tamilnadu &
2
B.S. Shakuntala, Former Dean, AECS Maruthi College of Nursing, Bangalore, Karnataka, India.
Correspondence:
T. Nirmala,
E-mail : nirmala_cbe@yahoo.com
Abstract :
Title : Effect of Concept Mapping in Development of Critical thinking (CT) Skills among B. Sc Nursing Students
Objectives : To evaluate the effectiveness of concept mapping as a teaching strategy to develop critical thinking skills. Materials and
Methods : Pretest, post test control group design was used. The IV year B.Sc nursing students were included as experimental group
(n=40) and control group (n=44). The experimental group was given a training to prepare nursing care plans using concept mapping. The
training programme was for 12 weeks where the participants were given case study scenarios every week to prepare nursing care plans
using concept map. The experimental group and control group were again assessed for the critical thinking skills. The concept maps
were evaluated using scoring criteria.
Results: In the post test, there was a significant difference in the critical thinking scores of both the groups at 0.05 level. (t= 2.16). A
significant improvement was identified between the pretest and post test critical thinking scores of experiment group at 0.05 level
(t=2.0). Comparison of concept mapping scores of the experimental group in the pretest and post test showed a highly significant
difference at 0.041 level.
Conclusion: The study was able to show a significant improvement in the critical thinking skills of nursing students. However, the critical
thinking scores were poor due to the high standard of the assessment tool. It is needed to develop critical thinking skill assessment tool
which will suit the nursing community and further research is required to promote concept mapping as a teaching and learning strategy.
Keywords : Concept Mapping, Critical thinking, nursing process

Introduction:
Critical thinking (CT) is currently a highly valued
educational outcome throughout the educational
spectrum, especially in relation to higher and professional
education. Nursing education worldwide is also embracing
the construct critical thinking as a desirable educational
outcome and realizes the importance of eliciting the
(1)
evidence of critical thinking in nurse's reasoning process.
Recent trends in nursing education have led the nursing
educators to promote meaningful learning among the
(2)
novice nurses. The new nurse graduates have to think
critically and solve problems in a variety of clinical
settings(3).
The present nurse educators feel that the nursing care
plans done by the students are not case sensitive and need
in-depth comprehension of client's physical, psychological,
social and spiritual health. It is felt by the student nurses
that writing nursing care plans is tiring and time consuming
effort. The lacunae in the objective evaluation of
traditional care plans demands the nursing educators to
research for an appropriate solution which will solve this
complex problem of presenting and evaluating the nursing
care plans more objectively. One of the best solutions for
this problem is the promotion of meaningful learning
through the usage of concept maps. In addition, the
concept mapping is recognized as a teaching strategy that
promotes critical thinking because it stimulates deep
(4, 5)
understanding among the learners. However, the
concept mapping hasn't gained its due attention from the
nurse educators.
In view of this, the present study aims to evaluate the
effectiveness of concept mapping in promotion of critical
thinking skills in nurses.
Critical Thinking and Concept Mapping: It is understood

CONCEPT MAPPING – AN EFFECTIVE TOOL TO PROMOTE CRITICAL 21

THINKING SKILLS AMONG NURSES - T. Nirmala

that critical thinking is purposeful, self-regulatory
judgment which results in interpretation, analysis,
evaluation, and inference, as well as explanation upon
(6)
which the judgment is based. Few definitions of critical
thinking defines it as reasonable, reflective thinking
focused on what to believe or do, the propensity to engage
in an activity with reflective skepticism, purposeful goal
directed thinking, the art of thinking about thinking while
thinking to make thinking better, purposeful and with self-
regulatory judgment. (7)
In nursing, critical thinking is the ability to think in a
systematic and logical manner with openness to question
and reflect on the reasoning process which is used to
ensure safe nursing practice and quality care. Critical
thinking when developed in the practitioner includes
adherence to intellectual standards, proficiency in using
reasoning, a commitment to develop and maintain
intellectual traits of the mind and habits of thought and the
competent use of thinking skills which will develop the
abilities for sound clinical judgments and safe decision-
making. (8)
The primary goal of nursing education is to assist nurses
and nursing students learn how to synthesize information,
think critically, and use clinical evidence appropriately.
Guiding students in these complex mental processes
requires nurse educators to choose learning activities that
move beyond teaching facts and their application to
prompting advanced critical thinking and clinical decision
making. Teaching nurses to think critically and use evidence
is a challenge because it requires educators to "see" the
learners' thinking. (9)
Concept mapping is a technique developed by Joseph D
Novak in 1970s for visualizing the relationships among
(10)
different concepts. The concept mapping is said to result
(11)
in meaningful learning and has been utilized for over 25
years as a valuable tool for meaningful learning in
(12)
educational settings.
The components of concept maps include meaningful
prepositions, connecting words, cross links and relevant
(13, 14)
examples. Among them, the cross links are responsible
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NUJHS Vol. I, No.4, December 2011, ISSN 2249-7110
Nitte University Journal of Health Science
and an evidence for the development of critical thinking or
meaningful learning which connects different vertical
(15)
linkages in the conceptual structure. The prepositions
can be rote learned whereas the cross links relate concepts
in different domains that promote the non – linear or
lateral thinking which is an essential quality of critical
thinking.
Many Healthcare Educators have recently adapted it as a
useful instructional aid to promote critical thinking and
prepare students for clinical practical experience. The
concept map assists students to correlate client's
diagnoses, symptoms, treatments, and interventions and
then problem solve in clinical decision-making. A quasi-
experimental study evaluated the effectiveness of
developing critical thinking skills in baccalaureate nursing
students using concept mapping as a teaching strategy and
the experimental group scores improved significantly (p <
.05) on an overall score and on analysis and evaluation
scales. (12)
A meta-analysis of the research studies with regard to
concept mapping demonstrates that this teaching-
learning method assists nurse educators to prepare
graduates to think critically in the complex health care
environment. (2)
Another study done in northeast Florida hospital found a
higher post concept map scores among the GNM students
(16)
(n=14) attending an orientation program. The same
result was replicated in another study with 28 associate
(17)
degree nursing students. A group of doctoral nursing
students expressed that while concept mapping, they liked
the problem solving and interactive nature of the activity,
logical reasoning for their decisions, deeper understanding
of the content and above all there is no one correct solution
(3)
to concept mapping. An online course on 'distance
education to adults' for the nursing used the concept
mapping and reflective journal to assess the thinking
process of the students and found that they helped the
students to self assess their own thinking processes. (18)
The maps foster a long term change in thinking and
contribute to changing adult students' learning strategies.

Sixty five percent of the students who participated in
research by doing concept mapping in the first semester
(19)
continued to use it in the next semester too. A quasi-
experimental study done in Mangalore city of India found
that there was a significant improvement in the concept
map score in a short-term training for one week (personal
communication)
Methodology :
A type of quasi-experimental study, pretest post test
control group design was used in this study. The final year
B.Sc. nursing students from two different college of nursing
were selected as experimental (n=40) and control group
(n=44). (Fig 1) During the final year, the nursing students
undergo intensive training in midwifery for one year along
with other subjects. This study included the case scenarios
from midwifery.
After obtaining the approval from the Institutional review
board (IRB), both the groups were given a standard tool
called 'thinking skill assessment tool' from Cambridge
University to identify their critical thinking level. The tool
contained 32 multiple choice questions involving all the
critical thinking skills. Following the pre-assessment, the
experimental group was given an introductory lecture on
Concept mapping and its applicability in nursing process as
the participants were not familiar with the use of concept
mapping.
After the lecture, the students in the experimental group
were divided into eight small groups of five. The groups
were given the first case study scenario from midwifery and
asked to make a concept map under the non-participatory
observation of the researcher. The eight concept maps
were evaluated using the scoring criteria as suggested by
Novak and Godwin as each meaningful preposition =
1score, Hierarchy = 5scores, Examples= 1score, and cross
links = 10 scores. The concept maps were evaluated by two
raters and inter rater reliability was determined using
Kappa method. It was found almost perfect. (Prepositions =
0.738, Hierarchy = 0.875, Examples= 1.0, Cross links = 1.0)
From the second week, the experimental group was given
case study scenarios every week and asked to make
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NUJHS Vol. I, No.4, December 2011, ISSN 2249-7110
Nitte University Journal of Health Science
concept map for the next 10 weeks. The group met three
days in a week for one hour. The group members were
designated as moderator, recorder, reporter, time keeper
and evaluator. The role is exchanged every week to ensure
the participation of each student. During the first day, the
students discussed and referred to the literature to learn
and clarify the concepts in relation to the given case
scenarios. On the second day, the students were asked to
make the concept map and on the third day, each group
shared their concept map with other groups. During the
discussion, the researcher encouraged the participants
indentify the individuality and differences in each concept
maps which helped the students in further sessions.
On the 12 week, the students were given the same first
case study scenario to do the concept map and were
evaluated for post test. Finally, the experimental group and
control group were again assessed for the critical thinking
skills using the same tool.
Results and Discussion:
The analysis of pretest scores of critical thinking skills
among both the groups revealed that the mean & STD of
critical thinking scores of experimental and control group
as 7.25, 7.9 and 2.8, 2.9 respectively. The pretest scores of
experimental group ranged from 1 to 13 and control group
from 3 to 14.
The mean and STD of post test critical thinking scores
among the experimental and control group was found to be
8.2, 3.0 and 7.7, 2.76 respectively. The post test scores
ranged between 2 to 16 in the experimental group and 3 to
14 in the control group.
The comparison between the pretest and posttest CT
scores of control group by Paired 't' test showed that there
was no significant difference between two which
determined that there was no change in the critical
thinking skills of the participants in the control group.(t =
0.661) (Fig 2)
The comparison of post test critical thinking scores of
experimental and control groups showed that there was a
significant improvement in the critical thinking scores
 NUJHS Vol. I, No.4, December 2011, ISSN 2249-7110

Nitte University Journal of Health Science

Assessment of CT skill
level using the "Thinking
Reassessment of
Skill Assessment" No Intervention
CT skills
prepared by Cambridge
University.

Control group (n=44)

Assessment of CT skill
Training to prepare
level using the "Thinking
concept maps for the Reassessment of
Skill Assessment"
given case scenarios CT skills
prepared by Cambridge
For 12 weeks
University.

Experimental group
(n=44)
Figure 1: Pretest Post test Control group design

Comparision of critical thinking scores of control group

30
25 25
25
No. of students

20

15 12 12
10 8 8

5
0 0
0
1 to 5 6 to 10 11 to 15 15 to 20
Pretest Posttest CT scores

Figure 2 : Pre and post critical thinking scores of control group

Comparision of critical thinking scores of Experimental group

30
25
25 22
No.of students

20
15
9 8 8 9
10
5
0 1
0
1 to 5 6 to 10 11 to 15 15 to 20
Pretest Posttest CT scores

Figure 3 : Pre and post test critical thinking scores of Experimental group

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 NUJHS Vol. I, No.4, December 2011, ISSN 2249-7110

Nitte University Journal of Health Science

Pre and post test scores of concept maps

600 557

500
388 373
400 349 358
Total Scores

320
282 282
300 234 261 227
192
200 176
148151 110
100 100
100
0
1 2 3 4 5 6 7 8
Mean
Pre test Post test Groups

Figure 4 : Pre and post concept map scores of Experimental group

Table 1 Critical Thinking scores before and after the training programme
S.No Group Pretest Post test 't' Value
Mean STD Mean STD
1 Experimental 7.25 2.8 8.2 3.0 t=2.0*
Group
2 Control 7.9 2.9 7.7 2.76 T=0.661
Group
T=2.16*

Table 2 Comparison of Pretest and Post test Concept Map scores

S.No Part of the Pretest Post test 't' value Significance
concept map Mean STD Mean STD
1 Preposition 45.87 6.4 60 17.5 2.603 p = 0.035
2 Hierarchy 5.1 0.7 5.9 1.1 1.0 p = 0.351
3 Examples 2 3.0 5.4 3.7 2.077 p = 0.076
4 Cross links 11.62 6.7 22.5 12.6 2.391 p = 0.048
5 Total Scores 192.25 68.9 319.75 143.6 2.506 p= 0.041

which depicted the effectiveness of the training
programme (t = 2.16, p = 0.05). A significant difference was
identified between the pretest and posttest critical
thinking scores of experimental group at 0.05 level (t = 2.0).
It again showed that the critical thinking scores improved
following the training programme. (Fig 3)
319.75 respectively. The comparison of pretest and post
test concept map scores showed significant difference in all
the aspects of concept map except for the hierarchy.(Table
1) The total post test concept map scores showed a
significant improvement from the pretest concept map
scores at p = 0.041 level (t = 2.506). (Fig 4)

The concept maps prepared by the fourth year nursing
students for the given case scenario in Midwifery were
evaluated using the scoring key. The mean pretest and post
test scores of concept maps for prepositions were (45.8,
6.0), for hierarchy (5.1, 5.8), for example (2, 5.4), for cross
links (11.6, 22.5) and for the total scores, it was 192.25 and
The different components of concept maps had shown
significant difference except the hierarchy level. The
Hierarchy level indicates the linear thinking which is not an
area of critical thinking, whereas the identification of
meaningful prepositions and cross links had shown a
significant difference which denotes non linear thinking in

25

students, indicative of significant development of critical
thinking.
The students felt that the concept map was very interesting
and they motivated them to think and reason out better.
Few of the students found it difficult initially and able to
draw the maps later. Few of them felt that it was difficult to
change the nursing process format now as they were used
to the traditional way of making nursing care plans for the
past three years. 'If it has been practiced from the first, it
would have been the best method to follow' they said. They
expressed that their thinking process has had a significant
change by doing the concept maps. They told that they
were able to see the relationships between the concepts
better and they could identify newer relationships which
they had not known or thought before.
Conclusion:
Though there was a significant improvement in the critical
thinking scores among the experimental group, the overall
scores of the experimental and the control group were
found to be very poor. The reason for the poor CT scores
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